NIH Stroke Scale (NIHSS) Group E Test Prep with
Actual Complete Questions, Correct Verified
Answers and Detailed Rationales Already Graded A+
| 2026 Updated
Master the NIH Stroke Scale Group E Certification with this definitive study resource. It features
the exact scoring benchmarks for patient 1 through 6, a detailed breakdown of all 11 core
clinical domains, and an advanced 100-question practice bank. Every question includes a clear
explanation and clinical Rationale to help you understand tricky edge cases, untestable
scenarios, and spatial neglect rules. Perfect for nurses, residents, and stroke-unit clinicians
aiming to pass on their first attempt!
,Questions 1–15: Domain-Specific Scoring Criteria
Question 1
A patient is drowsy but can be aroused by minor verbal stimulation to attend, answer questions,
or respond to a command. What is the correct score for Item 1a (Level of Consciousness)?
A) 0 - Alert
B) 1 - Not alert; somnolent
C) 2 - Not alert; obtunded
D) 3 - Comatose
Rationale: Item 1a scores a 1 for patients who are somnolent/drowsy but can be easily
aroused with minimal verbal stimulation to perform basic interactive tasks.
Question 2
When testing Item 1b (LOC Questions), the patient correctly states the current month but
mistakenly gives their age as 42 instead of 52. How should this be scored?
A) 0 - Answers both questions correctly
B) 1 - Answers one question correctly
C) 2 - Answers neither question correctly
D) 1 - But only if the patient has a known speech impediment
Rationale: Item 1b is rigidly scored; partial answers or near-misses do not count. The patient
got exactly one question right, warranting a score of 1. Aphasic or intubated patients who
cannot speak score a 2.
Question 3
During the assessment of Item 1c (LOC Commands), the patient successfully opens and closes
their eyes when asked. However, when asked to grip and release their non-paretic hand, they
fail to respond due to sudden inattention. What is the score?
A) 0 - Performs both tasks correctly
B) 1 - Performs one task correctly
C) 2 - Performs neither task correctly
D) 0 - Because eye closure is the primary command
Rationale: The patient must clearly perform both separate actions (open/close eyes AND
open/close hand) to get a 0. Since they only completed the eye command, the score is 1.
Question 4
A patient presents with an isolated, partial gaze palsy that can be overcome by voluntary
tracking, but the eyes do not move fully into the left lateral gaze. What is the score for Item 2
,(Best Gaze)?
A) 0 - Normal
B) 1 - Partial gaze palsy
C) 2 - Forced deviation
D) 1 - Only if the patient has a pre-existing strabismus
Rationale: Item 2 scores a 1 for a partial gaze palsy where lateral movement is restricted but
not completely fixed. A score of 2 is reserved for forced deviation or total gaze paralysis that
cannot be overcome by the oculocephalic reflex.
Question 5
When testing Item 3 (Visual Fields) using confrontation, a patient exhibits a clear and
reproducible loss of vision in the lower quadrant of the left eye only, while the right eye is
normal. This represents a quadrantanopia. What is the correct score?
A) 0 - No visual loss
B) 1 - Partial hemianopia
C) 2 - Complete hemianopia
D) 3 - Bilateral blindness
Rationale: Asymmetry or localized field cuts like quadrantanopia are scored as a 1 (partial
hemianopia). Complete loss of an entire half of the visual field scores a 2.
Question 6
A patient shows clear, subtle flattening of the right nasolabial fold when resting, but when they
smile or grimace to a noxious stimulus, their facial movements appear symmetrical. What is the
correct score for Item 4 (Facial Palsy)?
A) 0 - Normal symmetrical movements
B) 1 - Minor paralysis (flattening of nasolabial fold)
C) 2 - Partial paralysis (total lower facial flatting)
D) 3 - Complete paralysis
Rationale: Asymmetry that is minor or only visible at rest (such as a flattening of the
nasolabial fold or minor droop) is scored as a 1.
Question 7
While testing Item 5a (Left Motor Arm), the patient lifts their left arm to 90 degrees while
sitting. The arm immediately drops down toward the bed but stops and holds a steady position
at 30 degrees for the remainder of the 10-second count. What is the correct score?
A) 1 - Drift occurs but does not hit the bed
B) 2 - Some effort against gravity, but arm falls to intermediate height
C) 3 - No effort against gravity; arm falls immediately
, D) 4 - No movement at all
Rationale: A score of 1 means the arm drifts down but does not touch the bed or alternative
support. A score of 2 means the arm falls before the 10 seconds is up to an intermediate level,
failing to maintain the initial position against gravity.
Question 8
During the evaluation of Item 5b (Right Motor Arm), a patient can slightly twitch their fingers
and shrug their shoulder, but they cannot lift their arm off the bed at all. What is the score?
A) 2 - Some effort against gravity
B) 3 - No effort against gravity; limb drops
C) 4 - No movement
D) UN - Untestable
Rationale: If there is minor joint movement or twitching but the limb cannot lift against
gravity at all, it is scored as a 3.
Question 9
When evaluating Item 6a (Left Motor Leg), the patient holds their left leg at 30 degrees while
supine. The leg gradually drifts down and touches the mattress at exactly the 4-second mark of
the 5-second countdown. What is the score?
A) 0 - No drift
B) 1 - Drift; hits mattress at end of 4 seconds
C) 2 - Some effort against gravity; hits mattress immediately
D) 3 - No effort against gravity
Rationale: If the leg drifts but does not touch the bed before the full 5 seconds, or if it slowly
sinks and touches down right at the end of the countdown, it is scored as a 1. A score of 2
requires the leg to drop rapidly to the bed before 5 seconds.
Question 10
A patient has a cast on their right leg due to an ankle fracture three weeks ago, making it
impossible to evaluate leg drift. How should Item 6b (Right Motor Leg) be scored?
A) 0 - Normal by default
B) 4 - Complete paralysis
C) 9 - Missing data
D) Untestable (scored as 0 or skipped depending on electronic health record matrix, but
clinically documented as UN)
Rationale: Amputation, rigid casts, or mechanical joint barriers make the limb untestable. On
official examinations, this is documented as UN, and it is excluded from the final numerical
calculations.
Actual Complete Questions, Correct Verified
Answers and Detailed Rationales Already Graded A+
| 2026 Updated
Master the NIH Stroke Scale Group E Certification with this definitive study resource. It features
the exact scoring benchmarks for patient 1 through 6, a detailed breakdown of all 11 core
clinical domains, and an advanced 100-question practice bank. Every question includes a clear
explanation and clinical Rationale to help you understand tricky edge cases, untestable
scenarios, and spatial neglect rules. Perfect for nurses, residents, and stroke-unit clinicians
aiming to pass on their first attempt!
,Questions 1–15: Domain-Specific Scoring Criteria
Question 1
A patient is drowsy but can be aroused by minor verbal stimulation to attend, answer questions,
or respond to a command. What is the correct score for Item 1a (Level of Consciousness)?
A) 0 - Alert
B) 1 - Not alert; somnolent
C) 2 - Not alert; obtunded
D) 3 - Comatose
Rationale: Item 1a scores a 1 for patients who are somnolent/drowsy but can be easily
aroused with minimal verbal stimulation to perform basic interactive tasks.
Question 2
When testing Item 1b (LOC Questions), the patient correctly states the current month but
mistakenly gives their age as 42 instead of 52. How should this be scored?
A) 0 - Answers both questions correctly
B) 1 - Answers one question correctly
C) 2 - Answers neither question correctly
D) 1 - But only if the patient has a known speech impediment
Rationale: Item 1b is rigidly scored; partial answers or near-misses do not count. The patient
got exactly one question right, warranting a score of 1. Aphasic or intubated patients who
cannot speak score a 2.
Question 3
During the assessment of Item 1c (LOC Commands), the patient successfully opens and closes
their eyes when asked. However, when asked to grip and release their non-paretic hand, they
fail to respond due to sudden inattention. What is the score?
A) 0 - Performs both tasks correctly
B) 1 - Performs one task correctly
C) 2 - Performs neither task correctly
D) 0 - Because eye closure is the primary command
Rationale: The patient must clearly perform both separate actions (open/close eyes AND
open/close hand) to get a 0. Since they only completed the eye command, the score is 1.
Question 4
A patient presents with an isolated, partial gaze palsy that can be overcome by voluntary
tracking, but the eyes do not move fully into the left lateral gaze. What is the score for Item 2
,(Best Gaze)?
A) 0 - Normal
B) 1 - Partial gaze palsy
C) 2 - Forced deviation
D) 1 - Only if the patient has a pre-existing strabismus
Rationale: Item 2 scores a 1 for a partial gaze palsy where lateral movement is restricted but
not completely fixed. A score of 2 is reserved for forced deviation or total gaze paralysis that
cannot be overcome by the oculocephalic reflex.
Question 5
When testing Item 3 (Visual Fields) using confrontation, a patient exhibits a clear and
reproducible loss of vision in the lower quadrant of the left eye only, while the right eye is
normal. This represents a quadrantanopia. What is the correct score?
A) 0 - No visual loss
B) 1 - Partial hemianopia
C) 2 - Complete hemianopia
D) 3 - Bilateral blindness
Rationale: Asymmetry or localized field cuts like quadrantanopia are scored as a 1 (partial
hemianopia). Complete loss of an entire half of the visual field scores a 2.
Question 6
A patient shows clear, subtle flattening of the right nasolabial fold when resting, but when they
smile or grimace to a noxious stimulus, their facial movements appear symmetrical. What is the
correct score for Item 4 (Facial Palsy)?
A) 0 - Normal symmetrical movements
B) 1 - Minor paralysis (flattening of nasolabial fold)
C) 2 - Partial paralysis (total lower facial flatting)
D) 3 - Complete paralysis
Rationale: Asymmetry that is minor or only visible at rest (such as a flattening of the
nasolabial fold or minor droop) is scored as a 1.
Question 7
While testing Item 5a (Left Motor Arm), the patient lifts their left arm to 90 degrees while
sitting. The arm immediately drops down toward the bed but stops and holds a steady position
at 30 degrees for the remainder of the 10-second count. What is the correct score?
A) 1 - Drift occurs but does not hit the bed
B) 2 - Some effort against gravity, but arm falls to intermediate height
C) 3 - No effort against gravity; arm falls immediately
, D) 4 - No movement at all
Rationale: A score of 1 means the arm drifts down but does not touch the bed or alternative
support. A score of 2 means the arm falls before the 10 seconds is up to an intermediate level,
failing to maintain the initial position against gravity.
Question 8
During the evaluation of Item 5b (Right Motor Arm), a patient can slightly twitch their fingers
and shrug their shoulder, but they cannot lift their arm off the bed at all. What is the score?
A) 2 - Some effort against gravity
B) 3 - No effort against gravity; limb drops
C) 4 - No movement
D) UN - Untestable
Rationale: If there is minor joint movement or twitching but the limb cannot lift against
gravity at all, it is scored as a 3.
Question 9
When evaluating Item 6a (Left Motor Leg), the patient holds their left leg at 30 degrees while
supine. The leg gradually drifts down and touches the mattress at exactly the 4-second mark of
the 5-second countdown. What is the score?
A) 0 - No drift
B) 1 - Drift; hits mattress at end of 4 seconds
C) 2 - Some effort against gravity; hits mattress immediately
D) 3 - No effort against gravity
Rationale: If the leg drifts but does not touch the bed before the full 5 seconds, or if it slowly
sinks and touches down right at the end of the countdown, it is scored as a 1. A score of 2
requires the leg to drop rapidly to the bed before 5 seconds.
Question 10
A patient has a cast on their right leg due to an ankle fracture three weeks ago, making it
impossible to evaluate leg drift. How should Item 6b (Right Motor Leg) be scored?
A) 0 - Normal by default
B) 4 - Complete paralysis
C) 9 - Missing data
D) Untestable (scored as 0 or skipped depending on electronic health record matrix, but
clinically documented as UN)
Rationale: Amputation, rigid casts, or mechanical joint barriers make the limb untestable. On
official examinations, this is documented as UN, and it is excluded from the final numerical
calculations.
